INTRODUCTION:Urology residency graduates face a pivotal transition when deciding on fellowship training and eventual practice setting. While traditionally a fellowship was a gateway to academia, recent trends reveal increasing pursuit due to job market concerns and perceived gaps in operative preparedness. We aimed to identify factors influencing urological fellowship pursuit and subsequent career trajectories. METHODS:We analyzed a previously created database of publicly available information of ACGME-accredited urology residency graduates from 2022-2025. Data were obtained from institutional, residency, fellowship, and employment profiles. Outcomes included fellowship enrollment and employment in academia or private practice. Statistical analyses included Students t-tests, Mann-Whitney U, Chi-square tests, and multivariable logistic regression. RESULTS:Among 1,310 graduates identified, 46.0% (n=602) pursued fellowship training. Predictors of fellowship pursuit included female gender (53.0% vs 43.1%, p=0.001), holding another graduate degree (64.6% vs 43.9%, p<0.001), and graduation from a top-quartile Doximity-ranked program (51.9 % vs 34.0% of graduates in the last quartile, p<0.001). Overall, 75.2% of graduates entered private practice and 24.8% academia. Those within academia were more likely to have completed fellowship training (49.6% vs 11.9%, p<0.001), and a six-year residency with dedicated research year (33.0% vs 22.5%, p=0.002). Female gender was also associated with fellowship subspecialty choice, comprising 80% of URPS fellows compared with 22.1% of SUO fellows. CONCLUSIONS:Despite most graduates entering private practice, nearly half pursue fellowship training. Meanwhile, those working in academia are more likely to have completed a fellowship or trained in a six-year residency or a top-ranked program. Notably gender disparities persist in fellowship subspecialty selection.
PURPOSE:To identify component-level drivers of cost variability for intradetrusor onabotulinumtoxinA (BTX-A) injections for overactive bladder across office-based clinic, tertiary operating room (OR), and hospital outpatient department (HOPD) settings. METHODS:We performed a retrospective cost analysis of BTX-A injection encounters from January 2020 to June 2025 using institutional activity-based cost accounting data. Costs were grouped into procedural components and categorized as direct or indirect. Mean costs were compared using Welch's t-tests with Bonferroni correction. Utilization-adjusted variance decomposition identified component-level drivers of cost variability. RESULTS:The cohort included 322 tertiary OR, 125 HOPD, and 1,492 clinic encounters. Mean total costs were $4,633.87 in the tertiary OR, $5,063.32 in the HOPD, and $1,899.01 in clinic. Total cost variability differed by setting. In the tertiary OR, variability was driven by supplies (29.5%), OR time (25.7%), and post-anesthesia recovery (25.5%), while direct cost variability was dominated by supplies (45.1%) and indirect variability by OR time (56.0%). In the HOPD, total cost variability was driven by OR time (41.2%), anesthesia (29.2%), and recovery (16.1%), with similar drivers of indirect variability. In clinic, total and direct cost variability were driven primarily by cystoscopy (63.9% and 68.7%) and BTX-A (36.1% and 31.3%), while indirect variability was driven by BTX-A (65.4%). CONCLUSIONS:Cost variability differs substantially across procedural settings. Cost-containment efforts should target setting-specific variance drivers rather than mean costs or site of service alone.
INTRODUCTION:There is no standardized post-operative surveillance for upper tract reconstruction, with frequent use of nuclear medicine renal scans (NMRS). We propose a protocol utilizing renal ultrasonography (RUS) as the initial assessment tool, reserving secondary studies to evaluate patients with worse hydronephrosis or persistent symptoms. METHODS:Retrospective analysis of a prospectively designed imaging protocol at a single-institution, 2016-2022. The protocol uses screening RUS at 3 and 12 months, with NMRS or ureteroscopy (URS) as clinically indicated. Diagnostic accuracy of 3-month RUS was assessed with 95% confidence intervals. RESULTS:136 patients underwent ureteral reconstruction, accounting for 144 reconstructive procedures. Primary success rate was 91.9%, increasing to 94.1% after revision surgery. Among 110 renal units with paired baseline and 3-month RUS, hydronephrosis was improved in 65.5%, stable in 31.8%, and worse in 2.7%. Eleven patients required reintervention. Based on clinical suspicion and/or worsening imaging, 27 patients (19.9%) underwent NMRS and 18 underwent URS. Three-month RUS was highly specific (98.1%) for subsequent reintervention, and 102/107 renal units (95.3%) with stable/improved hydronephrosis required no intervention. Five of the six reinterventions among imaged units followed reassuring ultrasound and were identified by symptom-directed evaluation. CONCLUSIONS:RUS with clinical monitoring is an effective modality for post-operative surveillance following ureteral reconstruction, allowing more than 80% of patients to avoid NMRS. Stable or improved hydronephrosis reliably identified patients requiring no further intervention, while most failures were detected through symptoms rather than imaging alone. Nuclear scans and ureteroscopy should be reserved for patients with symptoms or imaging suggestive of obstruction.
INTRODUCTION:Advanced prostate cancer treatments carry substantial financial toxicity, which may be mitigated by generic alternatives. We characterize Medicare spending trends on branded vs generic abiraterone to estimate the impact of generic adoption on cost and access. METHODS:Medicare Part D data (2013-2023) were analyzed for all abiraterone formulations and compared with enzalutamide, which carries similar indications but no generic alternative. Annual percent change (APC) was analyzed using joinpoint regression. RESULTS:Generic abiraterone became available in 2018. Medicare spending on all abiraterone formulations increased from $470 million to $1.5 billion from 2013 to 2018 (APC 19.3%, P = .02) and then decreased from $1.5 billion to $910 million from 2018 to 2023 (APC -10.4%, P = .06). From 2013 to 2023, the number of beneficiaries receiving abiraterone annually increased from 14,188 to 46,411 (APC 12.3%, P < .01). From 2013 to 2017, the annual cost per beneficiary grew from $33,094 to $48,978 (APC 12.2%, P = .02) and then decreased to $19,610 in 2023 (APC -17.7%, P < .01). The per-refill cost of generic abiraterone decreased significantly after its introduction in 2018 (APC -17.2%, P = .01). Generic abiraterone adoption yielded total Medicare cost savings of $7.3 billion from 2018 to 2023. By contrast, enzalutamide displayed steady increases in total Medicare spending (APC 18.5%, P < .01) and per-beneficiary cost (APC 9.3%, P < .01) throughout the study period. CONCLUSIONS:Generic abiraterone adoption led to significant reductions in Medicare spending and cost per beneficiary, while maintaining a trend of increased utilization. These benefits were not seen with enzalutamide, which does not have a generic alternative. These findings underscore the importance of timely generic entry in controlling Medicare spending while preserving access to life-prolonging therapeutics.
INTRODUCTION:Obesity is a well-established risk factor for stress urinary incontinence (SUI); however, the relative contribution of central vs overall adiposity remains unclear. We hypothesized that central adiposity, measured by waist-to-height ratio (WHtR), would demonstrate a stronger association with SUI than BMI. METHODS:This cross-sectional study analyzed adult women participating in the National Health and Nutrition Examination Survey 2011 to 2018 cycles. SUI was defined as self-reported urine leakage during physical exertion, coughing, or sneezing. Anthropometric indices (BMI, waist circumference, and WHtR) were evaluated as continuous variables and quartiles. Survey-weighted multivariable logistic regression models were constructed adjusting for age, diabetes, smoking status, parity, menopausal status, and physical activity. RESULTS:A total of 5445 women were included, representing approximately 57.9 million US women. The weighted prevalence of SUI was 26.4%. All adiposity indices were independently associated with SUI; however, WHtR demonstrated the strongest association. Each 0.1-unit increase in WHtR was associated with a 30% higher odds of SUI (adjusted odds ratio 1.30, 95% CI 1.21-1.39), compared with a 4% increase per 1 kg/m2 increment in BMI. Women in the highest WHtR quartile had nearly a threefold higher odds of SUI compared with the lowest quartile. Associations were consistent across menopausal strata without significant interaction. CONCLUSIONS:Central adiposity, quantified by WHtR, appears to be more strongly associated with SUI than overall adiposity. Incorporating WHtR into routine clinical assessment may enhance risk stratification and help identify women who could benefit from targeted interventions aimed at reducing abdominal adiposity.
INTRODUCTION:PSA screening is influenced by social, structural, and interpersonal factors. We evaluated whether patient-reported domains of the patient-provider relationship were associated with PSA screening uptake. METHODS:We performed a cross-sectional analysis of men aged 40 years or older in the All of Us Research Program Controlled Tier data set version 8. The primary outcome was receipt of at least 1 eligible PSA test within a 4-year window spanning 2 years before through 2 years after survey completion. Exposures included respect, collaboration, ease of understanding, and relatability. Multivariable logistic regression was used to assess associations with PSA screening. RESULTS:Among 34,057 men, 10,848 (31.9%) underwent PSA screening. Screening rates decreased across lower response levels for respect, collaboration, and ease of understanding. After adjustment, lower perceived respect was associated with reduced odds of screening for "most of the time" (adjusted odds ratio [aOR] 0.89, 95% CI 0.83-0.95) and "some of the time" (aOR 0.71, 95% CI 0.59-0.86) vs "always." Lower collaboration was also associated with reduced screening odds across all nonreference levels (aOR range 0.83-0.94), while ease of understanding was significant only for some of the time (aOR 0.80, 95% CI 0.71-0.91). Relatability was not independently associated with screening. These findings were consistent across guideline-oriented age cohorts. CONCLUSIONS:Less favorable perceptions of respect, collaboration, and ease of understanding within health care interactions were associated with lower PSA screening uptake. These findings suggest that patient-provider relationship domains represent modifiable factors associated with access to informed, preference-concordant, and risk-appropriate PSA screening.
INTRODUCTION:Results from 3 randomized clinical trials (RCTs) established initial observation with early salvage radiotherapy as the standard of care for men with adverse pathology (AP) after radical prostatectomy (RP). The aim of our study was to assess whether the use of adjuvant radiotherapy (aRT) has declined since the 2020 publication of these RCTs. METHODS:We retrospectively reviewed the Michigan Urological Surgery Improvement Collaborative prostate cancer registry and identified men who underwent RP from 2012 to 2024 and approximated the inclusion criteria of the RCTs: postoperative PSA ≤ 0.1 ng/mL and at least 1 pathological feature (pT3a,pT3b,pT4, or positive surgical margins). The primary objective was to test the association of time period of RP (before 2020 vs 2020 vs after 2020) with the use of aRT vs initial observation. aRT was defined as radiation therapy that was started both within 12 months of diagnosis and with PSA ≤ 0.1 ng/mL. The Kaplan-Meier method and mixed-effects multivariable Cox regression were used to evaluate an association of time period with aRT. RESULTS:Of 9144 patients meeting inclusion criteria, 5408 had RP before 2020, 764 in 2020, and 2972 after 2020. Before 2020, 8.2% of patients (95% CI: 7.5%-9.0%) were treated with aRT, compared with 4.6% (95% CI: 3.2%-6.4%) in 2020 and 2.7% (95% CI: 2.1%-3.5%) after 2020. After adjustment in the multivariable model, patients undergoing RP after compared with before 2020 were less likely to receive aRT (odds ratio 0.24, 95% CI: 0.18-0.32, P < .001). CONCLUSIONS:The use of aRT decreased after 2020, consistent with level 1 evidence supporting initial observation in patients with AP.
INTRODUCTION:Intravesical chemotherapy (IC) administered perioperatively after nephroureterectomy (NUx) for upper tract urothelial carcinoma reduces intravesical recurrence based on 2 randomized trials and is endorsed by contemporary practice guidelines. However, real-world adoption of this intervention remains poorly defined. We evaluated national utilization trends and identified predictors of perioperative IC use after NUx. METHODS:Using the National Cancer Database, we identified patients with nonmetastatic upper tract urothelial carcinoma who underwent NUx between 2013 and 2022. Perioperative IC was defined as chemotherapy administered within 48 hours of surgery. Temporal trends were assessed using the Cochran-Armitage test. Multivariable logistic regression was used to identify factors independently associated with IC receipt. RESULTS:Among 14,808 eligible patients, only 1032 (7.0%) received perioperative IC. Utilization increased significantly over time, from 1.1% in 2013 to 16.6% in 2022 (P < .001). On multivariable analysis, treatment at an academic (odds ratio [OR] 2.47, 95% CI 2.09-2.91) or comprehensive cancer program (OR 2.24, 95% CI 1.86-2.69), later year of diagnosis (OR 1.37 per year, 95% CI 1.33-1.41), and ureteral tumor location (OR 1.22, 95% CI 1.06-1.40) were associated with higher odds of IC use. Hispanic ethnicity (OR 0.39, 95% CI 0.26-0.59), higher clinical T stage, and open surgical approach were associated with significantly lower odds of IC receipt. CONCLUSIONS:Despite level 1 evidence and guideline endorsement, perioperative IC after NUx remains infrequently used in the United States. Persistent disparities in adoption highlight a substantial evidence-to-practice gap and underscore opportunities for targeted implementation strategies to improve equitable delivery of guideline-supported care.
INTRODUCTION:Overactive bladder (OAB) is a prevalent condition associated with impaired quality of life, yet many patients do not pursue treatment or minimally invasive therapies (MITs). Physician-patient concordance has been proposed as a factor influencing trust, although its role in OAB care is not well defined. We evaluated the association between physician gender concordance and patient trust, and examined the relationship of trust with health literacy, medical mistrust, and treatment preferences for OAB among broad US consumers. METHODS:In this survey-based study, Black and White women were randomized to view 1 of 4 standardized videos describing OAB treatments, differing only by physician race and gender. Trust was dichotomized from a 4-point Likert scale. Participants reported treatment preferences and completed the eHealth Literacy Scale and Group-Based Medical Mistrust Scale. Associations were assessed using chi-square tests and multivariable logistic regressions. RESULTS:Among 1027 participants, physician gender concordance was not associated with trust (P >.05). Trust was strongly associated with both OAB diagnosis (P = .001) and selection of MITs (P < .001). Higher eHealth literacy independently increased the odds of trust (odds ratio 1.06, P < .001), whereas greater medical mistrust reduced the odds (odds ratio 0.94, P < .001). Income was also independently associated with trust. Race was not an independent predictor, although Black participants reported significantly higher medical mistrust. CONCLUSIONS:Greater patient trust increased likelihood of having an OAB diagnosis and selection of MITs. Health literacy and medical mistrust demonstrated stronger associations with trust than physician gender concordance, highlighting potential areas for improving patient engagement in OAB care.
